Provider Manual · Part VII

The patient chart

Everything in one record: find the patient, read the chart's tabs and header strip, keep problems, allergies, demographics, and vitals current, and review past encounters alongside upcoming visits.

7 sections~16 min read7 screenshots
VII
Part VII

The patient chart

Everything in one record: find the patient, read the chart's tabs and header strip, keep problems, allergies, demographics, and vitals current, and review past encounters alongside upcoming visits.

7.2Chart layout & tabs

Read the chart: layout, tabs & in-chart search

The chart screen has two zones: the patient header strip across the top (covered in the next section) and the Chart Review card below it, with a row of section tabs. Encounters is the default tab.

EncountersNotesLabsImagingMedicationsProceduresMediaLetters

Those eight are the row a default practice sees. Three more — Immunizations, Prenatal, and Brain Health — are conditional and slot in after Medications only where they apply, so don’t expect them on every chart. Each fails closed — if the setting is still loading, the tab stays hidden rather than flickering into view:

  • Immunizations appears only if your practice has enabled it as an additional feature (see Practice setup).
  • Prenatal needs obstetrics enabled and at least one pregnancy episode on this patient, so it shows up on the patients it applies to rather than on every chart.
  • Brain Health appears when the neurology brain-health feature is enabled for the practice.

For staff accounts, each tab shows only when the staff profile holds the matching permission — a profile with no chart permissions sees No chart sections available instead.

  1. Jump between tabs. Cmd+1Cmd+9 (Ctrl+1Ctrl+9 on Windows) go straight to a tab — hover any tab to see its shortcut hint. Only the first nine tabs you can actually see get a number, so on a chart carrying the optional tabs the last ones are click-only. Tabs load on first visit and then stay loaded, so switching back is instant. If the row overflows the window, chevron buttons appear to scroll it.
  2. Search inside the chart. The magnifier at the right end of the tab row expands a Search… box (Ctrl+F focuses it). It full-text searches the patient’s Notes, Labs, and Imaging, groups the matches under headings, and clicking a result jumps to that item in the matching tab.
  3. Pick a layout. The small monitor icon on the header toggles between the default horizontal bar (Switch to vertical layout) and a vertical left sidebar (Switch to horizontal layout) that lists Allergies, Problems, Other History, Immunizations (when enabled), Preferred Pharmacies, and Referral Communications as expandable sections. Referral Communications only appears when this patient came in through an inbound referral, and an active-pregnancy chip sits in the panel for obstetric practices.
  4. Order without opening a note. Physicians can press F7 or Ctrl+O from the chart to open Create Orders directly — see Standalone orders.
A full patient chart with the header strip showing vitals, Allergies, Problems, Pharmacies and Other History, the default tab row Encounters, Notes, Labs, Imaging, Medications, Procedures, Media and Letters, and the Encounters tab open with Sort and Filter chips, the Future Visits toggle pressed, the Customize columns icon at the right end of that row, an Upcoming Visits panel, and the encounter history table beneath it
The whole chart at a glance: header strip on top, tab row beneath it, and the default Encounters tab with upcoming visits above the history.
Know the search scope: in-chart search covers Notes, Labs, and Imaging only — it does not search medications, media, or letters. Browse those tabs directly.
7.3Patient header strip

The patient header: identity, vitals & safety at a glance

The header strip stays in view no matter which tab you’re on. It packs the patient’s identity, latest vitals, allergies, problems, and preferred pharmacies into one bar — each block is clickable and drops down its detail.

Identity

Avatar initials, name, MRN, age, DOB, and sex. Hover for a demographics summary tooltip; click to open Patient Information — for physicians and admins a full workspace page in its own Info: {patient} tab, and for staff without a patient-chart permission the same content as an overlay dialog. In the vertical layout the MRN is a badge — Click to copy MRN.

Vitals readout

The most recent Wt: and Ht: with a recency suffix such as “(today)” or “(3d ago)”, or No vitals recorded when empty. Clicking it opens the vitals action menu — see Vitals & trends.

Allergies

A live count; the dropdown sorts severe-first with Severe / Moderate / Mild / Unknown pills. Add New records one, and clicking a listed allergy opens it for editing.

Problems

A live count; the dropdown has All / Active / Inactive / Resolved filter chips, sorts active problems first, and badges the rest. Add New adds to the list.

Pharmacies

Drops down the Preferred Pharmacies list. The gear opens Manage and Select Pharmacies — set a primary, remove entries, or search under Add New Pharmacy. See Pharmacies for the full workflow.

Other History

Opens past surgical, social, and family history in one dialog. The button is there for physicians and admins; staff need the patient-history permission (patient_history.manage) to see it at all.

Sticky note

Physicians (not staff) get a yellow Sticky Note button that opens a draggable per-patient note. It autosaves and reopens automatically whenever it has content.

Pharmacy edits aren’t saved until you click Save Changes in the manage dialog — closing it discards your changes. Removing the primary pharmacy silently promotes the first remaining one to primary.
APCM practices see one more chip: if your practice has APCM enabled, primary-care physicians also get a heart-pulse status chip (for example APCM: Eligible or APCM: Enrolled) that can document verbal enrollment consent — see the APCM program.
7.4Problems & allergies

Maintain the problem list & allergies

Problems and allergies are managed straight from their header dropdowns, and both follow the same add–edit–delete pattern. Keeping them current matters beyond the chart: the allergy list feeds the medication safety checks (see Safety checks).

  1. Open the dialog. Click ProblemsAdd New, or press Ctrl+Shift+P anywhere in the chart; for allergies it’s AllergiesAdd New or Ctrl+Shift+A. To edit, just click an existing entry in the dropdown.
  2. Name the entry. A problem requires an ICD-10 Code: type into Search ICD-10 codes… and press Enter (or the magnifier) to open the code search; the official description appears beneath the field once chosen. An allergy requires an Allergen Name via Search allergens… — pick a database match or keep your free-text entry.
  3. Fill in the detail and save. Save with Add Problem or Add Allergy. When editing, the button reads Update Problem / Update Allergy and the code or allergen is read-only — only the details below can change.
  4. Delete with confirmation. Open the entry and click Delete; an inline Confirm delete? prompt with Yes / No appears before anything is removed.

Problem details

  • Notes — free text, up to 5,000 characters.
  • Severity (1-10) — annotated (Mild) 1–3, (Moderate) 4–7, (Severe) 8–10.
  • StatusActive, Resolved, or Inactive.
  • Chronic Condition checkbox.

Allergy details

  • Severity — Mild / Moderate / Severe / Unknown (defaults to Moderate); severe allergies sort to the top in red.
  • Reaction Type — Rash, Hives, Itching, Swelling, Respiratory, Anaphylaxis, GI Upset, Nausea, Vomiting, Diarrhea, Headache, or Other.
  • Reaction Description — locked by design unless the type is Other, where it becomes required.
  • Notes — up to 5,000 characters.
Problems dropdown open from the chart header with All, Active, Inactive and Resolved filter chips, a problem list carrying Inactive and Resolved status badges, and an Add New button
The Problems dropdown: filter chips, color-coded status dots with Inactive / Resolved badges, and + Add New.
Codes and allergens can’t be renamed. Once saved, a problem’s ICD-10 code and an allergy’s allergen are locked — to correct a wrong one, delete it (or mark the problem resolved) and add a new entry.
An empty allergy list isn’t blank: the chart shows a green No Known Allergies indicator instead, so you can tell “reviewed, none” apart from “never asked.”
7.5Demographics & insurance

View & edit demographics, insurance, and patient billing

Click the patient’s name or avatar in the header strip and Hero EMR opens Patient Information — one screen for everything administrative about this patient. For physicians and admins it is a full workspace page in its own tab titled Info: {patient}; staff without a patient-chart permission get the same content as an overlay dialog. Its header repeats the identity with chips for MRN, DOB, Age, and Sex, and it opens on Demographics.

Ten tabs sit in a grouped sidebar: Demographics under Patient; Appointments, Forms & Letters, Prescriptions, Prior Auth, and Questionnaires under Care workflow; Custom Billing Rules, Insurance, and Invoices & Charges under Financial; and Outbound Comms under Administration. The financial and administrative tabs are permission-gated, so a plain physician account works with seven of the ten.

The whole screen has its own chapter: the Patient Information overview for who sees which tab and the ?section= deep links, Demographics for the edit form and its validation, and Insurance & eligibility for policies, the free eligibility check and the paid COB check, and the cash-pay bypass.

The Patient Information workspace open on Demographics in its own Info: Michael Chen tab, with the left sidebar grouped as PATIENT (Demographics), CARE WORKFLOW (Appointments, Forms & Letters, Prescriptions, Prior Auth, Questionnaires), FINANCIAL (Custom Billing Rules, Insurance, Invoices & Charges) and ADMINISTRATION (Outbound Comms), the header chips MRN, DOB, Age and Sex, an Edit button, and the Identity, Contact, Address and Emergency Contact cards
Patient Information as a workspace page — grouped sidebar, identity chips, and the Demographics read cards.
7.6Encounters & notes

Review past encounters, notes & upcoming visits

The Encounters tab — the chart’s default — is the visit history: every encounter in a sortable table, a side-by-side preview, and an optional panel of upcoming visits. The Notes tab is the note-centric view of the same record.

  1. Scan the history. Columns are Date, Type, Provider, Specialty, and Chief Complaint, and dates render in your organization’s time zone. Badges sit next to the type and tell you the state of each visit at a glance: Unsigned note while a note is still a draft, Signed once you’ve signed it, plus No-show, Rescheduled, or Cancelled where the appointment didn’t happen, and Portal restricted on a visit whose note you’ve kept out of the patient portal. Switch on the optional Status column and those badges move there rather than doubling up. Long histories load 50 encounters at a time as you scroll, with a Showing N encounters banner and All encounters loaded marking the end of the record.
  2. Sort and filter. The Sort chips (Date / Type / Provider / Specialty) toggle ascending and descending. The chips follow your columns: every sortable column you have switched on gets a chip, so adding or hiding columns changes what you can sort by. The Filter chips narrow to All, By Me, or My Specialty. The last two are grayed out for staff accounts without a physician record — that’s expected.
  3. Choose your columns. The Customize columns button — the small columns icon at the right-hand end of the Sort / Filter row — opens a column manager. Beyond the five that show by default you can add Summary, Status, Visit Reason, Last Updated, and Signed, plus Billing, Claim, and Balance — those last three are money columns and are simply absent for users who can’t see financial amounts. Your choice is saved to your own account, so the table looks the same on every chart you open.
  4. Preview a visit. Single-click a row to open a split-pane preview — note content, orders, and charges — and collapse it with Hide Preview / Show Preview. Double-click to open the same preview as a near-full-screen dialog instead.
  5. Open the visit itself. A thin action strip sits above the split-pane preview: Encounter on the left, and on the right an Open encounter button that takes you into the note writer for that visit — to keep writing a draft, or to add an addendum to one you’ve already signed. On a row from the Upcoming visits panel the same button reads Begin encounter and starts the visit instead. The strip belongs to the split-pane preview only, so if you double-clicked into the full-screen window you’ll need to close it and single-click the row instead. Staff accounts see the strip only with an encounter permission on their profile.
  6. Watch upcoming visits. The Future Visits toggle (on by default) shows an Upcoming visits panel above the history with a count: each booked appointment’s date and time, visit type with an Upcoming badge, provider, location or Virtual Visit, and any visit notes. Cancelled, completed, no-show, held, and already-started visits are filtered out automatically; with nothing booked it reads No upcoming visits scheduled.
  7. Read notes on the Notes tab. The sortable note list opens any note in a preview pane beside it. Columns are Date, Note Type, Document, Specialty, and Author; a note that has been signed shows a Signed: date beneath its date, and Document shows a dash where the note came from a visit rather than an imported or uploaded document. Sort by: offers Date, Note Type, Specialty, and Author; the Filter by: pills are All Notes, My Specialty, and By Me. Customize columns chooses the columns, Hide Preview / Show Preview collapses the reading pane, and All notes loaded marks the end of the list.
  8. To change a signed note, open its visit. Signed notes are never edited in place, and the Notes tab has no editing controls at all — it is a reading surface. Go back to the Encounters tab, single-click the visit, and click Open encounter in the preview’s action strip (or double-click the appointment on the calendar). Hero EMR asks whether you want to create an addendum, copies the signed note as your starting point, and you sign the amended version when you’re done. Full walkthrough in Change a visit after you’ve signed it.
  9. Read earlier versions with History. Once a note has been amended, the list shows the current version only — the addendum takes the original’s place rather than sitting beside it as a second row. Nothing is lost: select the note and click History, the clock button in the preview toolbar beside Print (tooltip: View version history). A Version History column opens listing every version by date and time with its author. Click an entry to read that version in full. The version you’re reading is badged Current; the Active badge that every entry carries means something else — that the version’s full text is still stored and instantly readable, rather than moved to long-term storage (Archived) once it passes your practice’s retention window.
Encounters tab with the preview pane open, showing a New Patient Visit with Draft and Telehealth badges and a Visit logistics card
Single-click opens the split-pane preview — here a draft telehealth visit with its Visit logistics card.
Notes tab with a sortable note list, a Progress Note selected, and its preview shown alongside
The Notes tab: pick a note on the left, read it on the right.
Encounters tab split-pane preview with the Encounter action strip above it and a blue Open encounter button at its right-hand end
The action strip above the split-pane preview — Open encounter takes you into the note writer for that visit.
The upcoming-visits panel is read-only. Rows are display-only — booking or changing appointments happens in the scheduling workspace (see Work the calendar), and visits shown as Virtual Visit run through telehealth.
7.7Vitals & trends

Vitals: read the strip, record during a visit, review the trend

The header’s vitals readout shows the most recent Wt: and Ht: with a recency suffix — “(today)”, “(yesterday)”, “(3d ago)”, or a date — or No vitals recorded when there’s nothing yet. Clicking it opens a small action menu for everything vitals-related.

  1. Open the action menu. Click the Wt: / Ht: readout. The three standing actions are Open height and weight trends, Pull latest vitals into note, and Add encounter vitals. Obstetric practices get a fourth, OB, during a visit — it opens prenatal observations for the encounter, or offers Start pregnancy episode… when there isn’t one yet.
  2. Review the trend. Open height and weight trends opens the Growth & vitals trends modal. Three tiles across the top give you Latest weight, Latest height, and Most recent at a glance; below them, Weight and Height tabs chart every recorded value point by point, each with a Date / Value / Source table under the chart. Children get a third tab, Growth, plotting the measurements against CDC growth percentiles — it appears for patients under 20 and opens selected by default under 18.
  3. Record vitals during a visit. Add encounter vitals opens a dialog subtitled Save measurements for the patient on this encounter. It records Measured at (required), Weight and Height with unit selectors, Head circumference with its own cm/in selector, Blood pressure (Systolic/Diastolic), Heart rate, Temperature with its unit, Oxygen saturation, Respiratory rate, Pain (0-10), and Notes. Finish with Save vitals.
  4. Stamp vitals into the note. Pull latest vitals into note inserts the most recent measurements into the encounter note you have open, so the documented vitals match the chart.
Vitals entry is part of a visit, not free-standing. Pull latest vitals into note and Add encounter vitals stay disabled unless a draft encounter note for this patient is open — their tooltips read “Open an editable encounter note to pull vitals into the note.” and “Open an editable encounter to add encounter vitals.” Start the note first (see the encounter workspace); of the standing three actions, only the trends view is not tied to an open note, and the OB action needs an encounter too.

Need help? Email support@heroemr.com.